Archived: Tulipa House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider continued to fail to ensure oversight and governance were effective. Significant shortfalls identified during this assessment had not been identified, or when shortfalls had been found they had not been acted on in a timely way. There was not a robust approach to creating a culture of learning lessons, listening and continuous improvement.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders did not ensure there was a clear shared vision and strategy which staff in all areas knew, understood and supported. The registered manager and staff did not demonstrate a learning culture which focused on listening, learning and driving improvements. There was no clear vision and set of values shared throughout the staff team. There were differences in staff empathy and understanding. Whilst the registered manager felt people should be able to live their lives to the fullest, they recognised that there was a need to get all the staff on-board.

The registered manager had identified that not all staff were performing well, however we were unable to see what action was being taken to address this. One member of staff said, “I think the management is trying to make it a home for people, but the staff are the problem.” Staff felt the service valued equality diversity in the workforce.

The registered manager had identified issues within the staff team, however sufficient action had not been taken to address this in a timely way. The management team had not identified some of the shortfalls found during the on-site assessment. Lessons had not been learned following the warning notices, served after the previous inspection. The management team failed to take action in a timely way when concerns were identified. Staff did not always feel the management team took action when needed. Staff told us, “Some staff need to pull their finger out. There is always something to do. Some staff stand around doing nothing” and, “[The registered manager] is supportive as is the deputy manager who is willing to get their hands dirty”.

Action had not been taken to address a poor culture within the staff team. Whilst the registered manager told us they were planning a team building day, the staff told us there were issues within the team. They said some staff worked well and others did not. There were significant shortfalls relating to the analysis of incidents and accidents. The checks and audits were not robust and effective. Some shortfalls identified during the assessment had been noted by the registered manager, however action had not been taken to address them. Other shortfalls had not been identified by the management team.

Staff were positive about the registered manager. Staff did raise some concerns with the registered manager who was approachable. However, feedback from some staff about how supported they felt to drive forward improvement was mixed. One staff said, “I do not feel supported when staff and seniors are not pulling their weight, it is pushed back on us to fix.” Some relatives told us they had been asked to complete a survey about their relative’s care and support, however others had not. Some relatives knew how to complain, and others did not.

There were mechanisms in place for people to provide feedback. There were meetings for people where people had the opportunity to feedback. There had recently been a survey focusing specifically on meals although this was in progress at the time of the assessment. However, systems and processes had not always ensured the service was always open and transparent as some safeguarding concerns were not identified and shared with the local authority safeguarding team at the time they occurred.

Diversity of the workforce was valued. Reasonable adjustments, such as additional support with training, had been implemented. Staff told us, “They are flexible around childcare needs” and, “There is one resident who says not nice things and the manager will speak to the resident. They stand up for us.” The registered manager understood the need for staff to be treated equally. The services trainer spoke about supporting staff with any additional needs around training and sat with staff to support them with online training when needed.

The provider had an equality and diversity policy. Staff met their line manager regularly for one-to-one supervision. Safe recruitment processes were in place and the employee workforce turnover was monitored.

Staff were not always happy with how the service was governed. Some staff told us they felt documentation was in need of improvement at the service. One staff said this was because they prioritised care and didn’t have time to do both. Another staff said, “I have raised this with [the managers], and they start to pull something together. It’s good for a week or two and then it goes back to how it was.” There were areas where staff practice needed more oversight and leadership. Some staff told us they were assigned some tasks to do such as getting people up in the morning and completing body maps for people. However, staff were not clear on some aspects of care such as supporting people to go to the toilet or monitoring their continence needs. Communication also needed to be improved. One staff told us there was no hot water in some bedrooms and some bathrooms. This was the case. The registered manager and the provider told us they were aware there had been a problem a few days prior but thought that it had been resolved.

The provider continued to fail to ensure systems were robust enough to demonstrate safety was effectively managed. Where quality checks were in place, they had still not led to concerns always being identified or actioned in a timely manner. For example, checks had not identified multiple systems for recording incidents had led to some safeguarding incidents not being identified and reported to safeguarding and CQC in a timely manner. Audits did not always clearly identify concerns. For example, a pathway in the garden was not in good condition and was uneven. This had not been identified in the maintenance and grounds audit for May which stated all footpaths were in good condition. However, there was a new maintenance lead in place who had started to address other maintenance concerns and had a clear action plan in place. Documentation continued to be poor. We observed one person’s clothing had a large wet patch. The person used continence aids but had soaked through to their clothing. We asked for the person to be supported to change. On the person’s daily notes there were no records of support with continence or pad changes since they had got up that morning. Oral care was not always well recorded and there was a lack of information on if people were supported to clean their mouth, teeth or dentures. Records were not always accurate. Care plans continue to need updating. One person’s care plan stated they were on a medicine for a two-week trial, administered by a nurse who visited daily. The registered manager who told us they started on the medicine before Christmas and was still taking it. The person’s care plan had not been updated. There were concerns about the accuracy of records as notifications dates were not correctly recorded. We received several notifications which stated the registered manager was informed about an incident on or about the date the notification was sent. This was not the case, and they were informed prior to this.

Not everyone was able to tell us about their experience of living at Tulipa House. We spoke with relatives and a visiting health care professional. People were referred to health care professionals, such as speech and language therapists, for advice and additional support. A relative told us their relative had not seen a dentist as the staff were not able to take them. Another relative confirmed their relative was supported to see an optician. One relative said, “[My relative] does have chiropodist I know that. As far as I know they do have a joined-up approach.”

Staff worked with health care professionals for advice and to ensure people received the care and support they needed. When advice was given, staff followed this. For example, when people required a soft textured meal, we observed these were provided.

We requested feedback from the local authority; however, no feedback was received. The local authority had visited the service the previous year and provided some recommendations in their report. These recommendations had not all been actioned. For example, accident and incident analysis had not been completed to ensure safeguarding concerns were reported. A visiting health care professional told us they did not have any concerns. They felt the employment of a deputy manager had had a positive impact. They said referrals were made on time where appropriate.

Processes to inform the local authority and Care Quality Commission about incidents had not been followed. During the assessment we identified several safeguarding incidents which had not been reported in a timely manner. These were submitted after the assessment.

There was not a learning environment at the service. Staff had undertaken some training. However, they did not always demonstrate that training was put into practice. Some staff were clearly working hard and trying to provide good care. However, some staff said they were not always able to do so because there was not enough staff to support person centred care and other staff were not always engaged or well managed. One staff said, “There is always something to do. Some staff stand about doing nothing.”

The provider had failed to learn lessons and had not effectively made and sustained sufficient levels of improvement. After the last inspection we wrote to the provider and told them how they must improve. These improvements had not all been made. The provider continued to fail to do all that was reasonably practicable to mitigate risks to people. Incidents of potential abuse had still not always been identified at the time they had occurred. Some concerns were still not raised with the local authority safeguarding team prior to the assessment to ensure people were safe from the risk of potential abuse. The systems in place to review incidents for patterns and trends across the service still needed to be improved. Care plans continued not to be up to date. Quality assurance systems continued to not be effective to drive forward improvement. Staff skills needed to be improved and staff more effectively guided and managed. The culture of the service was poor, and the providers oversight had not been robust enough to lead the service to good. Medicine administration issues had been addressed and medicines management had improved.